Considerations for restorative dentistry secondary care referrals - part 3: assessment of case complexity.

Assessing the complexity of a case is a challenging exercise, with many tooth-specific as well as patient-specific considerations required. This decision is not made in isolation but goes hand in hand with the assessment of restorability, as well as strategic importance, both of which have been covered by the previous papers in this series. A number of guidelines regarding this matter have been devised in order to aid clinicians in determining the complexity of their patients and thus the most appropriate setting for their treatment. This paper aims to discuss the various complexity criteria available and their application, thus aiding clinicians in managing some of the more challenging cases.

Considerations for restorative dentistry secondary care referrals - part 1: defining strategic importance.

Strategic importance is an essential concept for dental service providers. It allows clinicians to differentiate treatment needs on both a patient level and a health care commissioning level, not simply based upon complexity alone. On a patient level, it influences both the clinician's and patient's decision as to whether a tooth/teeth should be restored, as well as determining the possible need for specialist input. On a commissioning level, it facilitates the prioritisation of limited resources.Strategic importance can be considered at a patient level, taking into factors such as age, tolerance to treatment and the patient's choice. It can also be considered at a mouth level, accounting for factors such as its impact on function and aesthetics function. All these factors together can influence the decision as to whether complex treatment is warranted on a given tooth, especially in a healthcare model where the allocation of limited resources is necessary.

Considerations for restorative dentistry secondary care referrals - part 2: predictability of treatment.

The assessment of restorability is necessary to determine whether it is possible to predictably restore a tooth once primary disease has been managed.There are a multitude of factors that may determine the restorability of a tooth. It varies on a case-by-case basis and as such, clinicians must consider both local tooth factors and general patient-related factors, ensuring a holistic approach when assessing these patients.This article discusses the many factors that determine a tooth's restorability, including a review of the current indices available to clinicians to aid in this process.

Early identification of malignancy in trismus: ten-year evolution of a trismus checklist to improve patient safety.

Introduction Trismus has been identified as a red flag sign that may lead to an early identification of a malignant lesion. A simple checklist was devised to allow clinicians to identify patients who may be at risk.Methods The implementation of this checklist at the temporomandibular disorder clinic of the University Dental Hospital of Manchester has been audited through ten annual cycles, each examining a sample of 50 clinical records of patients referred to the clinic. The standards set were that the presence of the trismus checklist in new patient examination notes should be 100%, the recording of mouth opening should be 100% and that the trismus checklist should be correctly filled in 100% of the time.Results The incidence of trismus ranged from 0-20%. The presence of the trismus checklist in new patient examination notes ranged from 78-100% compliance. The recording of mouth opening ranged from 80-100% compliance. The trismus checklist was not always filled in correctly: it ranged from 50-100%.Conclusion The use of audit has led to the evolution of the checklist and to improvements in its implementation. The trismus checklist has aided the early identification of malignancy. Future work should look at its implementation in a wider range of settings.

Cystin genetic variants cause autosomal recessive polycystic kidney disease associated with altered Myc expression.

Mutation of the Cys1 gene underlies the renal cystic disease in the Cys1cpk/cpk (cpk) mouse that phenocopies human autosomal recessive polycystic kidney disease (ARPKD). Cystin, the protein product of Cys1, is expressed in the primary apical cilia of renal ductal epithelial cells. In previous studies, we showed that cystin regulates Myc expression via interaction with the tumor suppressor, necdin. Here, we demonstrate rescue of the cpk renal phenotype by kidney-specific expression of a cystin-GFP fusion protein encoded by a transgene integrated into the Rosa26 locus. In addition, we show that expression of the cystin-GFP fusion protein in collecting duct cells down-regulates expression of Myc in cpk kidneys. Finally, we report the first human patient with an ARPKD phenotype due to homozygosity for a deleterious splicing variant in CYS1. These findings suggest that mutations in Cys1/CYS1 cause an ARPKD phenotype in mouse and human, respectively, and that the renal cystic phenotype in the mouse is driven by overexpression of the Myc proto-oncogene.

Hymenasplenium volubile: documentation of its gametophytes and the first record of a hemiepiphyte in the Aspleniaceae.

BACKGROUND AND AIMS: Through careful field examination of the growth habit of the gametophytes and sporophytes of Hymenasplenium volubile across an ontogenetic series, we aim to understand better the evolution of epiphytism in this poorly understood group of ferns. METHODS: We made field observations of H. volubile sporophytes and gametophytes, and brought specimens back to the lab for microscopic analysis. In the field, sporophytes at each ontogenetic stage were photographed to document the species' growth habit. We used an existing phylogeny to optimize growth form of New World Hymenasplenium. KEY RESULTS: Young sporophytes were at first fully epiphytic and produced one or two long feeding roots that extend to the soil where they branch profusely. The feeding roots remain in contact with the soil throughout the life of the plant. Thus, H. volubile is a hemiepiphyte. While immature, gametophytes are appressed to the tree trunk, but, as their gametangia mature, their lower margin lifts upward, imparting a shelf-like appearance to the thallus. The thallus attaches to the substrate by branched rhizoids produced along the margin of the thallus in contact with the substrate. CONCLUSIONS: Hemiepiphytes are a key link in the evolution of epiphytic ferns and may act as a bridge between the forest floor and the canopy. Our finding is the first report of hemiepiphytism in Aspleniaceae, a large lineage with many epiphytic and terrestrial taxa. This work serves as an important model to understand the evolution of epiphytism in this group specifically and in ferns in general. The majority of our understanding of fern gametophyte biology is derived from laboratory studies. Our efforts represent a fundamental contribution to understanding fern gametophyte ecology in a field setting.